We recently received a delay of service denial for a NICU baby. The baby needed a non emergent procedure. Because of the fragility of the baby, they were combining 2 procedures at once. Two specialty peds surgeons were involved as well as peds cardiac anesthesia – also complicated by needed a block of a few hours in the OR. It took 2 weeks from the time the needed procedure was identified to when the surgery was scheduled/performed. We received a delay in service denial for 7 days prior to the surgery. Is there some industry “evidence based criteria” standard they are basing this on that you are aware of?

We did not find any published standards pertaining to this situation, though keep in mind that we are not lawyers. We suggest that you check the contract with the payer and see if they define “delay in care” for nonemergent procedures. We also suggest appealing based on the facts that the procedures were non-emergent, the baby was very fragile and complicated planning needed to be accomplished to combine two procedures into one operative session, taking into account the availability of two specialized pediatric surgeons and a pediatric cardiac anesthesiologist. In addition, the OR needed blocked off for an extended period of time, which can take time unless conditions are emergent.

We suggest making a point that the baby would not have been discharged from the NICU had the procedures been done earlier (if that is indeed the case) and that the delicate condition of the baby required the procedures to be done at the optimal time for the baby, as determined by the physicians. If it’s true that no harm came to the baby as a result of the procedures being pushed out, we suggest stating that as well. If the baby was in a better condition at the time of surgery than when the payer thinks it should have been done, that would be something to put in your appeal as well.

Answered by: Karla Hiravi, BSN, RN Vice President Clinical Resources, AHDAM and PayerWatch